EAQ Tissue Integrity

A client who is to receive radiation for cancer says to the nurse, "My family and friends say that I will get a radiation burn." What is the best response by the nurse?

"A localized skin reaction usually occurs."

A 6-year-old child has partial-thickness burns of the face and upper chest. What is the priority nursing assessment for the first 24 hours?

Pulmonary distress

A client understands that an increase in both vitamin E and beta-carotene is important for healthier skin. What foods should the nurse include in her teaching that are excellent sources of both?

Spinach and mangoes

A client has a pressure ulcer that is full thickness with necrosis into the subcutaneous tissue down to the underlying fascia. The nurse should document the assessment finding as which stage of pressure ulcers?

Stage III

Which of the following nursing interventions promotes perfusion and healing of the surgical wound for an older adult?

The nurse should keep the client adequately hydrated.

A health care provider prescribes the application of a warm soak to an intravenous (IV) site that has infiltrated. What principle does the nurse determine is in operation when the application of local heat transfers temperature to the body?

Conduction

Which integumentary manifestation can be noticed in a client with CD4+ count of 180/mm3/(200/uL)?

Delayed wound healing

A client with scleroderma reports having difficulty chewing and swallowing. What should the nurse recommend to safely facilitate eating?

Eat a mechanical soft diet

A client with scleroderma reports having difficulty chewing and swallowing. What should the nurse recommend to safely facilitate eating?

Eat a mechanical soft diet.

After 2 weeks of radiation therapy for cancer of the breast a client experiences some erythema over the area being radiated. The area is sensitive but not painful. She states that she has been using tepid water and a soft washcloth when cleansing the area and applying an ice pack three times a day. What does the nurse conclude from this information?

Further teaching on skin care is necessary.

A client develops an increased temperature after surgery. Ceftriaxone is prescribed. For which potential effect should the nurse monitor the client?

Allergic response

Which skin infection experienced by a client is treated with an intralesional injection?

Alopecia areata

A client has a diagnosis of partial-thickness burns. The nurse recalls that the client's burn is different than full-thickness burns in that partial-thickness burns do what?

Are often painful, reddened, and have blisters

Which medical condition is treated by intravenous administration of calcium gluconate?

Hypoparathyroid tetany

A nurse is developing a teaching plan for a client with scleroderma. What should the nurse include about skin care?

Keep skin lubricated with lotion.

The nurse discovers several palpable elevated masses on a client's arms. Which term most accurately describes the assessment findings?

Papules

A client is admitted to the hospital with deep partial-thickness burns to both hands and forearms after an accident. How should the nurse apply the prescribed antimicrobial medication?

Place the medication directly on the burn wound in a thin layer using sterile gloves.

A nurse is caring for a client with a below-the-knee amputation. What should the nurse encourage the client to do to prepare the residual limb for a prosthesis?

Press the end of the residual limb against a pillow periodically

A client with an above-the-knee amputation asks why the residual limb needs to be wrapped with an elastic bandage. What does the nurse explain is the purpose?

To support the soft tissue and minimize swelling

A nurse is assessing the adequacy of a client's intravenous fluid replacement therapy during the first 2 to 3 days after sustaining full-thickness burns to the trunk and right thigh. What assessment will provide the nurse with the mostsignificant data?

Urinary output every hour

A client with the diagnosis of breast cancer is scheduled to receive radiation therapy to the affected area. The nurse teaches the client about how to care for the area that will be irradiated. The nurse determines that further teaching is necessary when the client states that to avoid skin irritation and breakdown the client will do what?

Use an oatmeal-based lotion after each treatment

A client is being treated for pressure ulcers. The primary healthcare provider advises the client to eat foods with high amounts of vitamin C. What is the role of vitamin C in wound healing?

Vitamin C is required for collagen production by fibroblasts.

A client had a colostomy surgery and is learning how to care for the skin around the stoma. What information from the teaching plan should the nurse reinforce with this client?

Wash the area gently with soap and water before applying an appliance

A client has a stage III pressure ulcer. Which nursing intervention can prevent further injury by eliminating shearing force?

With the help of another staff member, use a drawsheet when lifting the client in bed.

When assessing a wound that is healing by secondary intention, the nurse can classify it according to its condition and color. How should the nurse classify a wound that exhibits some soft necrotic tissue with a semiliquid slough and exudate?

Yellow